“I have to go through security—back in two,” Jason said, mid-couples session with his wife Lisa. His face disappeared from the screen, then I saw a white ceiling, then total darkness. It took me a minute to realize what was going on: Jason’s phone was on the conveyer belt at airport security, and I was seeing the inside of the X-ray machine. Meanwhile, Lisa continued talking to me as though nothing unusual was happening.
During the pandemic, many of us have realized how convenient teletherapy can be for us and our clients: We can have sessions at previously impossible times, like the middle of the workday, at night when kids are home, or, in Jason’s case, while travelling. The benefits are clear. But lately my supervision group has been discussing: Is the flexibility of teletherapy leading to more casual behaviors that take away from the therapeutic process? Do therapists need to set new boundaries with clients to ensure that online therapy is effective?
“I told my client it wasn’t okay for him to take our therapy calls outside his apartment, in case someone overhears him,” Vanessa, a member of my peer supervision group, shared with us. And yet she was hesitant about how exactly to set boundaries with her teletherapy clients. I knew what she meant.
I’d recently faced numerous moments when I’d been uncomfortable, unsure quite what to allow during sessions. Earlier that same day, I’d started a virtual session with a couple while they were waiting for their check at a restaurant. Then there’s my client Mia, who often calls into couples sessions while driving through the leafy New York suburbs with her fiancé Robert in the passenger seat. She’d turn off the camera and insist it was safe for us to have the session because she took calls from the car all the time. And then there’s Carol and Tony, a high conflict couple whose sessions tend to be smoother and more productive when they’re in different locations. But more than once, during our time together, Tony has dialed in from the office and replied to work emails he said were urgent.
The question of how to draw boundaries during teletherapy arises when clients are at home, too. My clients Jack and Joleen were attending therapy with the goal of putting the erotic spark back into their 12-year marriage. During one of our Zoom sessions, Joleen sipped a bottle of beer as they reclined on their couch. Should I allow that? Then, in my next session, I was working with Marc and Sienna to repair their relationship after Marc’s infidelity. They didn’t have a babysitter for our sessions, and their 10-year-old son kept coming into the room and interrupting us mid flow, as he did every week.
My best guess is that our therapeutic work was hindered in all these scenarios—clients were distracted and likely unable to fully process the therapy content, plus there were potential risks to confidentiality. My supervision group peers have echoed the same concerns. As therapists, we’re responsible for the effectiveness of treatment and for our clients’ wellbeing. And that means we need new boundaries for teletherapy. What should we keep in mind as we set them?
To set clear, fair boundaries, first we have to acknowledge the reasons that many of us are reluctant to limit how clients can engage with us, especially in teletherapy sessions during the pandemic:
We want clients to show up. Clients are busy, and the convenience and flexibility of online therapy is appealing to them. Instating rules that they need to be somewhere fully private and uninterrupted (and in the same room as their partner in the case of couples counseling) may increase cancellations or deter clients from starting therapy at all. Surely, it’s better for clients to show up to therapy and not be 100% present than to not show up at all?
We want to preserve the therapeutic relationship. When I tell clients their behavior is not acceptable and must change, no matter how kindly, I feel teacher-like, and know that some client will experience shame and embarrassment. When the client-therapist relationship is fragile (and it can be, especially with teletherapy clients who we’ve never met in person) we don’t want to give the client an excuse to check out. We also don’t want to make life harder for clients—there may be good reasons why they can’t be home for sessions or don’t have childcare.
We like learning about clients. When clients show up to therapy as they wish, we receive valuable information about their lives and the therapeutic work required. When Joleen showed up with beer as we discussed “sexual menu” items, I realized that discussing sexual preferences may be particularly hard for her. When Mia and Robert called from the car, I noticed how much time management was affecting their relationship. When Marc and Sienna’s son kept interrupting our session, I could see how the demands of parenting affected their relationship.
We encourage and respect our clients’ autonomy and judgement. Clients tend to know what they need, and I don’t want to assume that I know better. Charlie, 38, lived with his parents, and chose to take our therapy sessions from the sidewalk outside. Though his parents couldn’t hear him speaking in his room, knowing they were in the same home blocked his ability to speak freely, and that helped me understand why one of his main goals in therapy was to differentiate from his family. My client Melissa would clam up when talking about a past trauma, but when she walked in a local park during our sessions, she could access buried emotions. Whether consciously or unconsciously, clients often find ways to make therapy work for them.
With these values in mind, it’s clear that a one-size-fits all strategy won’t work for setting boundaries for teletherapy. The most effective boundaries are likely to be specific to the client and the therapist and will depend on factors like client’s diagnosis, comfort with technology, and the kind of therapy and treatment.
Here are four tips for navigating setting teletherapy boundaries while maintaining a trusted alliance and effective therapy.
Set boundaries early. Create a list of boundaries that are necessary for you to conduct successful online therapy with clients. During your initial call, be clear and direct with clients about what your guidelines are and why you have them. For example, you may want to explain to couple clients that they cannot do sessions on the run as it will hinder the development of their communication and active listening skills. You may also want include your expectations in your intake paperwork.
Take a step back to evaluate. Unless a client’s behavior is putting them at immediate risk, it’s okay not to set a boundary immediately and to wait until next session, or to see whether the behavior is a one-off or a trend. Take the time to seek advice from a peer or supervisor. When Joleen drank beer during couples therapy, before saying something, I consulted with a colleague who specializes in drug and alcohol issues. In our next session, I shared psychoeducational information on intoxication and therapeutic effectiveness with her, and we agreed that future sessions would be alcohol-free.
Collaborate and stay flexible. Start an open, curious conversation with clients around the behaviors you’ve observed and your potential concerns and ask about their perspective. To Tony, I might have said, “I noticed you seemed a little distracted in last week’s session, and that you checked your work email several times. What was your experience of the session? Do you think these things are connected in any way?” I could ask Melissa to tell me more about her choice to walk and talk during sessions rather than sit in one place. Hopefully, you can make a joint agreement based on what you both believe will make the therapy successful. You can continue to assess and revise the agreement later if needed. By initiating these conversations, you’re modeling collaboration and boundary-setting to clients.
Reflect on your own patterns. Managing teletherapy boundaries also gives therapists a chance to reflect on our own growth areas. Those of us who find it hard to set boundaries with clients may be pleasers by nature, struggle with assertiveness, or have a fear of rejection. Those of us who are quick to set boundaries, or who set rigid boundaries, may be uncomfortable with ambiguity, unpredictability, and not being in control.
Teletherapy best practices are still a work in progress. As we all adjust to this new normal, it’ll help us immensely to share our doubts, struggles, questions, and insights with one another. Preferably, not while taking off our shoes at the airport.
Talia Litman, MFT, is a marriage and family therapist and author specializing in couples and sex therapy. Contact: taliamft.com
Photo © iStock/damircudic
Topic: Professional Development